Inadequate dietary diversity practices and associated factors among pregnant adolescents in the West Arsi Zone, Central Ethiopia: a community-based cross-sectional study

The aftermath of dietary modifications made during pregnancy has the most substantial effects on nutritional status and birth results, despite the important influence of nutritional reserves. Numerous studies have been conducted on dietary practices and their determinants among pregnant women; however, there is a gap in evidence among pregnant adolescents. Therefore, this study sought to close this gap by examining dietary practices and associated factors among pregnant adolescents in the West Arsi Zone, Central Ethiopia. This community-based cross-sectional study was conducted among 459 pregnant adolescents between February and March 2023. Cluster sampling was used for selecting pregnant adolescents. Structured questionnaires were used for data collection. The data were entered into the Kobo toolbox and exported to SPSS version 25 software for analysis. Dietary diversity was assessed using the 24-h dietary recall method. Binary and multivariable logistic regression analyses were used to identify independent predictors of dietary practices. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated to identify the factors associated with the outcome variables. A p value ≤ 0.05 indicated statistical significance. The prevalence of inadequate dietary practices among the pregnant adolescents was 78.4% (95% CI 74.3%, 82.8%), and a level of nutritional knowledge [AOR = 2.4, 95% CI (1.82–4.74]; an unfavorable attitude toward dietary diversity [AOR = 4.3, 95% CI 2.9–5.83]; a food insecurity status [AOR = 8.7, 95% CI 2.37–10.24]; and a low perceived severity of poor dietary practices [AOR = 4.7, 95% CI 3.26–5.47]. These factors were significantly associated with inadequate dietary practices among pregnant adolescents. The most frequently consumed foods were starchy foods (81.3%) and pulses (79%), and the least consumed foods were meat (2.8%) and fruits (3.48%). The magnitude of inadequate dietary practices was high, and it was significantly associated with educational, behavioral, and economic status. Nutritional interventions focused on communicating nutritional behavioral changes and strengthening sustainable income-generating strategies are recommended to improve the dietary practices of pregnant adolescents.

Considering the design effect of 2 and adding a 10% nonresponse rate, the sample size was 431; however, the current study is part of follow up study [PACTR202203696996305.]registered at www. pactr.org, and sample size calculated for other objective was 488, which is greater than this, therefore sample size for this study was 488.
Pregnant adolescents were identified using a multistage clustered sampling technique.Four districts were chosen at random from 16 districts of the zone in the first stage.The second stage involved selecting kebeles, the lowest administrative entity, at random from the districts that had been chosen.After that, pregnant adolescents were counted during house-to-house visits to each of the chosen kebeles, and all pregnant adolescents visiting the selected kebeles were included in the study.The last menstrual period (LMP) was used to determine pregnancy among pregnant adolescents, and a pregnancy test was used to confirm pregnancy.The health extension workers and women's development army served in the identification of pregnant adolescents.Six clusters were from both Dodola Rural Adaba districts, and eight clusters were from both Gedeb Hasasa and Siraro districts.

Data collection procedure and measurements
The data were gathered using a pretested structured questionnaire.The questionnaire included questions on sociodemographic factors, meal frequency, health service usage, dietary categories, HFIAS (Household Food Insecurity Access Scale), crop diversity, and livestock diversification.Data on the HBM constructs were collected from two MPH (master of public health) holders and six clinical nurses who were hired as supervisors and data collectors, respectively.Three female laboratory technicians were also employed to perform pregnancy tests.At the participants' residences, the data collectors conducted face-to-face interviews to complete the questionnaire.Other family members were not allowed to access the location where the interviews took place to protect the pregnant adolescents' privacy to the fullest extent possible.
Dietary intake was calculated using multiple-pass 24-h recalls in accordance with the Food and Nutrition Technical Assistance (FANTA) III recommendation from the Food and Agricultural Organization and the United States Agency for International Development.The goal was to determine whether pregnant teenagers' diets are diverse 34 .According to the recommendations, there are ten food groups, including grains, plantains, white roots and tuber pulses (peas, beans, and lentils), dairy plants, meat, nuts and seeds, eggs, dark green leafy vegetables, poultry and fish, other vegetables and other fruits, and other fruits and vegetables rich in vitamin A. A pregnant adolescent was deemed to be consuming a sufficiently diverse diet if she had consumed at least five of the foods on the aforementioned lists in the 24 h prior to the data collection period 35,36 .Participants were asked to recall every meal they had and drink they had consumed during the preceding 24 h, both inside and outside of the home.In addition, the participants were prompted to recall any between-meal snacks they may have had.Food items were scored as "1" for consumption over the reference period and "0" for nonconsumption.
The HFIAS Guideline 36 was used to assess food security.Twenty-seven questions on the Household Food Insecurity Access Scale were used to evaluate the households' level of food security.Prior to this, the questions were approved for use in underdeveloped nations 37 .Food-secure households experienced fewer food insecurity indicators than did the first two food insecurity indicators.Households that experienced between two and ten, 11-17, or more than 17 food insecurity indicators were considered mildly, moderately, or severely food insecure, respectively.
Using principal component analysis (PCA), the household's wealth index was calculated by considering access to a latrine, a water source, household possession, animals, and agricultural land.The responses of the nondummy variables were divided into three categories.The highest rating is assigned a code of 1.However, the two lower numbers received a code of 0. In PCA, factor scores were generated using variables with a commonality value greater than 0.5.To calculate the wealth score, the first primary component score for each family is retained.To categorize households as poorest, poor, medium, rich, or richest 31 , quintiles of the wealth score were developed 31 .
Eight questions were used to measure the autonomy of pregnant adolescents.When a choice was made by the woman alone or jointly with her husband, code one was assigned for each question; otherwise, code zero was assigned.The ability of pregnant adolescents to make decisions was categorized according to the mean score 38 .
With the help of 12 questions, maternal knowledge of food intake during pregnancy was evaluated.When a response was correct, a code of one was issued; otherwise, a code of zero was given.Twenty items on the Likert scale were used to analyze attitudes via PCA.The factor scores were summed and divided into three portions, or terciles.The highest tercile was then classified as favorable, if not unfavorable 31 .

Operational definitions
Adequate dietary diversity: Pregnant adolescents who consumed food from 5 or more food groups within 24 h of day/before data collection [MDD-W, minimum dietary diversity for women was used] 34 .
Inadequate dietary diversity: Pregnant adolescents consumed food from fewer than 5 food groups on the day/within 24 h before data collection 34 .
Nutrition knowledge: Pregnant adolescents' knowledge of optimal nutrition during pregnancy was scored as follows: Pregnant adolescents with scores ≥ 75 and > 50% from 12 knowledge questions were considered to have high and medium knowledge scores, respectively.Otherwise, they are considered to have a low knowledge score 39 .www.nature.com/scientificreports/

Data quality control
By employing a standard, adapted questionnaire and adhering to the steps required to produce the desired results, the highest possible level of data quality was ensured.To maintain the uniformity of the questions, the questionnaire was translated into the local languages Amharic and Afan Oromo and then translated back into English.Pretesting was performed using a 5% sample size.Based on the gaps found during the pretest interview, changes were made to the data collection methods to improve reliability.The principal investigator provided a two-day training session for the data collectors and supervisors on the goal and methodology of the data collection, and they also participated in mock interviews and actual field exercises.To ensure the accuracy of the data, supervisors monitored the field practices and reviewed the completed surveys each day.

Reliability and validity of the data collection tools
A test-retest method was used for reliability analysis of the pregnant adolescent nutritional knowledge variable, and questions were reviewed to assess whether the results were the same for all respondents.A Cronbach coefficient of 0.83 was obtained after the pretest.To ensure validity, nutrition experts from Dilla University, the Department of Nutrition, were involved in checking the questionnaire to ensure that the questions elicited the required response, and a pretest was also conducted.

Data management and statistical analysis
The data were collected using Kobo Collect/Toolbox and subsequently exported to SPSS version 25 for cleaning and analysis.The intraclass correlation coefficient (ICC) was calculated and found to be 0.01, suggesting that there was little variation between groups and that the group-level effect was negligible; therefore, the traditional logistic regression model was used in this study.To identify independent predictors of dietary diversity, a binary logistic regression model was applied.In the bivariate analysis, variables with p values less than 0.25 were added to the multivariate logistic regression model.The 95% confidence intervals (CIs), crude and adjusted odd ratios (CORs) and AORs were used to calculate the strength of the relationship.According to the multivariate logistic regression analysis, variables with a P value of 0.05 or lower were regarded as independent predictors of dietary diversity.Collinearity between predictor variables was checked using the variance inflation factor (VIF); the maximum VIF was 2.8.

Ethical approval and consent to participate
Ethical approval was obtained from the Jimma University IRB/ethics committees with reference number JUIH/ IRB/194/22 and the Oromia Regional Health Office.All methods were performed in accordance with the relevant guidelines and regulations and in accordance with the Declaration of Helsinki.Informed consent was obtained from all participants and/or their legal guardians.Each study participant received a thorough description of the study's title, goal, protocol, and duration, as well as the potential risks and benefits, prior to providing informed consent.Each teenager provided verbal, written, and signed informed consent prior to any interview or measurement.Participants were made aware of the publication of their anonymous comments.Informed consent was obtained from participants prior to the commencement of interviews.The researcher remained truthful to the academic and ethical requirements.Finally, the researcher kept the data in a locked file cabinet in a safe place after the completion of the study.Informed consent was obtained from both the adolescent and their husband or parents.Any ethical issues that arose during this research were resolved through discussion between the researcher and JU's IRB.Finally, nutritional education interventions based on the results were continued after this study.

Sociodemographic and obstetric characteristics of pregnant adolescents
A total of 459 pregnant teenagers participated and response rate was 94%.The mean (± SD) age of the pregnant adolescents was 18.2 (± 0.97) years.According to the wealth index, only 17.4% of the respondents were classified as the richest people (Table 1).

Nutrition knowledge and attitudes of the participants
The nutritional knowledge of the study participants was assessed; accordingly, 269 (57.6%) of the respondents had a low level of nutritional knowledge.Approximately 338 (72.4%) had unfavorable attitudes toward good nutritional practices during pregnancy.

Obstetrics and health service-related characteristics
Approximately 122 (26%) of the pregnant adolescents underwent ANC follow-up, and a total of 170 (37%) of them received nutrition education during their follow-up (Table 2).

Inadequate dietary diversity of participants
Seventy-eight percent of the pregnant adolescents had inadequate dietary diversity practices during the preceding 24 h of the survey (95% CI 74.3%, 82.8%), and 21% had adequate dietary diversity practices.The most frequently eaten foods were starchy foods (81.3%) and pulses (79%), and the least consumed foods were meats (2.8%) and fruits (3.48%) (Fig. 1).

Factors associated with inadequate dietary diversity practices
Nutritional knowledge, attitudes toward acceptable dietary practices, food security, perceived susceptibility, household decision making, receiving nutritional education, perceived benefits and perceived severity were www.nature.com/scientificreports/associated with dietary diversity practices according to bivariate logistic regression analysis.Multivariate logistic regression analysis revealed that nutritional knowledge, attitudes toward acceptable dietary practices, food security and perceived severity of poor dietary practices were significantly associated with the dietary practices of pregnant adolescents.The odds of having inadequate dietary practices among pregnant adolescents who had a low level of nutritional knowledge were approximately two times greater than those who had a high level of nutritional knowledge [AOR = 2.4, 95% CI 1.82-4.74].Regarding attitudes, the odds of having inadequate dietary practices among pregnant adolescents who had unfavorable attitudes toward acceptable dietary practices were four times greater than those who had favorable attitudes [AOR = 4.3, 95% CI 2.9-5.83].The odds of having inadequate dietary practices among food insecure pregnant adolescents were approximately nine times greater than those among food secure adolescents [AOR = 8.7, 95% CI 7.37-10.24];additionally, the odds of having inadequate dietary practices among pregnant adolescents who had low perceived severity of poor dietary practices were four times greater than those who had high perceived severity [AOR = 4.7, 95% CI 3.26-5.47](Table 3).

Discussion
This study aimed to assess dietary diversity practices and associated factors among pregnant adolescents.Seventyeight percent of the pregnant adolescents had inadequate dietary diversity practices, and nutritional knowledge, attitudes toward acceptable dietary practices, food security and perceived severity of poor dietary practices were associated with the dietary practices of pregnant adolescents.The Food and Agriculture Organization (FAO) and World Health Organization (WHO) recommend that all mothers attain minimum dietary diversity scores to ensure micronutrient adequacy 34 .The magnitude of inadequate dietary diversity in this study was greater than that reported in several related studies, such as those conducted in Ghana (56%) 40 , South Africa (75%) 41 , Kenya (39%) 42 , the Gurage Zone, Southwest Ethiopia (58%) 43 and the Jimma Zone, Southwest Ethiopia (48.3%) 44 .Possible explanations for this might be that because the study was conducted among pregnant adolescents and because the aforementioned studies, except for the study conducted in Ghana, involved pregnant adults.This might be caused by differences in food security, employment level, and nutritional knowledge.Moreover, pregnant adolescents with less than 16 weeks of gestation were included, and the majority were primigravida, which had the highest incidence of hyperemesis gravida; these conditions may alter dietary practices and lead to food selection.Due to their low dietary diversity, pregnant  www.nature.com/scientificreports/teenagers are more likely to be deficient in nutrients, particularly micronutrients, which could affect the chances of having a healthy pregnancy outcome.
The other main finding of this study was that the odds of having inadequate dietary practices among pregnant adolescents who had a low level of nutritional knowledge were greater than those among pregnant adolescents who had a high level of nutritional knowledge, and these findings are consistent with those of studies conducted in Khartoum, Keniya 45 , Ghana 46 , West Kenya 47 and China 48 .This could be explained by the fact that changes in attitudes and knowledge are important antecedents of behavioral change, and nutritional knowledge is predictive of changes in dietary habits 49 .
Dietary practices can improve during pregnancy because pregnant individuals are more interested in learning about food and nutrition than they are before conception 50,51 .Additionally, different studies conducted in Ethiopia have shown that knowledge of nutrition among pregnant individuals is lower 52,53 ; therefore, nutritional behavioral change communication interventions (NBCCs) should be designed and delivered well for pregnant individuals, especially pregnant adolescents who are immature, at higher risk, hard to reach and underserved.The NBCC needs to be based on behavior change models and focus on the benefits of a diversified diet.
Adolescents frequently become pregnant unintentionally, and studies in Ethiopia revealed that only approximately 27% of them receive antenatal care (ANC) services 54,55 .As a result, they miss out on crucial nutritional education and adopt unhealthy eating habits, which makes them even more susceptible to undernutrition and other negative health outcomes.The government should oversee its implementation and enhance the quality of nutrition education because it is a less expensive and more efficient technique, particularly in areas with limited resources.
The odds of having inadequate dietary practices among pregnant adolescents who had unfavorable attitudes toward acceptable dietary practices were greater than those participants with favorable attitudes.This evidence is supported by studies conducted in southern Ethiopia 56 , the Gojjam zone, northern Ethiopia 31 , and Kigeme, Rwanda 57 .A possible explanation for this difference might be that pregnant adolescents with a positive attitude toward their maternal diet are more likely to intend to consume a balanced diet, which has a direct impact on their dietary practices.
Another finding is that the odds of having inadequate dietary practices among food insecure pregnant adolescents were greater than those among food secure adolescents.This result is in agreement with the findings of studies conducted in the Illu Aba Bor Zone, southwestern Ethiopia 32 , Tigray, Ethiopia 58 and the Gurage Zone, southern Ethiopia 43 .Adolescents are exposed to coping mechanisms that force them to limit the types and amounts of food they consume when food supplies are scarce.In developing nations, nutrition policies, strategies, and programs need to pay more attention to adolescent nutrition in general and pregnant adolescent nutrition and food security in particular.This study revealed that the odds of having inadequate dietary practices were greater among pregnant adolescents who reported poor dietary practices than among those who reported low perceived severity.There are similarities between this evidence and those of studies conducted in northeastern Ethiopia 30 and in the West, Gojjam Zone, and Ethiopia 59 .This may be because adolescents who were pregnant perceived that eating poorly during pregnancy had serious negative consequences for both them and their unborn child.Depending on how significant they perceive the consequences to be, a person's propensity to alter their health-related behavior is affected 60 .
One of the risk factors for healthy eating is the perceived severity of the effects of poor maternal diet, and it is one of the constructs of the health belief model (HBM).An interpersonal model of health called the HBM is used to promote constructive behaviors 61 .It clarifies why some people make efforts to improve their health while others do not.Its constructs consist of perceived susceptibility, severity, barriers to a specific behavior, benefits, self-efficacy and cues to action 61,62 .In nutrition education sessions, health care providers should consider using models such as the HBM.It is important to explain and discuss during counseling the negative effects of eating inadequate amounts of unbalanced meals, the vulnerability to and severity of those negative effects, the advantages of eating a healthy diet, and the obstacles to eating a balanced diet.

Strength and limitations
In this study, individuals consumed meals within the previous 24 h.are taken into account, which may not accurately reflect their typical eating patterns.Dietary intake can change during bumper or lean seasons as well as during celebrations, none of which were taken into account in this study.The 24-h.The data do not represent the long-term dietary habits of the participants.Despite its limitations, this study has contributed new knowledge to the scientific world, particularly in the setting of Ethiopia, on the variables that affect dietary diversity among pregnant teenagers.

Conclusion
Compared to the findings of other studies, this study showed that the extent of inadequate dietary practices was high.The study demonstrated that inadequate dietary practices in pregnant adolescents were associated with inadequate nutritional knowledge, an unfavorable attitude toward acceptable dietary practices, food insecurity, and the perceived severity of inadequate dietary practices.Pregnant adolescents should receive nutritional intervention that focuses on nutritional education based on behavioral modification models to enhance their dietary practices.Interventional studies to enhance dietary diversity practices are needed.Moreover, sustainable income-generating activities and strategies are recommended. https://doi.org/10.1038/s41598-024-53467-5

Figure 1 .
Figure 1.Dietary diversity practices of pregnant adolescents in the West Arsi zone, central Ethiopia.

Table 1 .
Sociodemographic and economic characteristics of pregnant adolescents in west Arsi zone, central Ethiopia, 2023 (n = 459).

Table 2 .
Obstetrics and health service-related characteristics of pregnant adolescents in the West Arsi Zone, central Ethiopia, 2023 (n = 459).